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THR Insurance Denial questions

DA32561

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Hi everyone, my THR is scheduled for a week from today and i just found out that my precertifcation was denied by my insurance company. The next step is a peer to peer review. I did call Evicore, the company that denied the surgery, and was told it was because I did not meet the criteria for surgery at this time. One of the criteria need to be moderate or severe osteoarthritis which is what I have! Has anyone dealt with this situation? I have gone for all the presurgical testing and clearances already and as you all know am in extreme pain everyday. My questions are, has anyone had this situation; does anyone know if the insurance reviews the xrays independentantly; do they often come to a conclusion different than the surgeon and radiologist? I would love to hear anyone's experience with this situation and how it worked out for them. I am currently waiting to hear back from my surgeons office regarding what I discovered on my own by just calling the insurance company to make sure my ducks were in a row. I haven't even received the formal denial in the mail yet. Today I am supposed to stop my NSAIDs and the pain will soon start progressing even more day by day. Certainly hope it's not for naught. Thanks for listening.
 

djklaugh

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@DA32561 I am so sorry you are having to deal with this! I am not familiar with the company you mentioned but hopefully your surgeon's office is ! Usually the business manager or office manager at surgeon's office is very skillful at dealing with insurance companies. I'd say stick to the current plan and keep in touch with your surgeon's office. I will send up prayers that this mess up will get quickly resolved :prayer:
 

Celle

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I am currently waiting to hear back from my surgeons office regarding what I discovered on my own by just calling the insurance company to make sure my ducks were in a row. I haven't even received the formal denial in the mail yet.
Keep calling your surgeon's office. They will be used to dealing with this sort of problem and they can probably sort it out for you.
 

Going4fun

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Yes, bug your surgeon's office. They should be on top of this and will have experience (most likely) with dealing with various insurance plans.

I got the sense that my insurance company preferred that I try out pt before the surgery. I did multiple years earlier ... anyway, it got through.

You'll most likely find a way to get approved. Work with your doctor's office. Usually surgeons (and all providers) have on staff someone who is expert at filling out insurance info (from their end) so that surgeries get approved.
 
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DA32561

DA32561

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@DA32561 I am so sorry you are having to deal with this! I am not familiar with the company you mentioned but hopefully your surgeon's office is ! Usually the business manager or office manager at surgeon's office is very skillful at dealing with insurance companies. I'd say stick to the current plan and keep in touch with your surgeon's office. I will send up prayers that this mess up will get quickly resolved :prayer:
Thank you, my actual insurance is through Aetna, but Evicore is the company through which the appeals are made. As a follow up, I did call my surgeons surgery coordinator. I will say I did feel like I was being giving the run around at first. She isn't in yet, she's out to lunch etc etc. But in the end she did speak to me and said that they are trying to arrange a time for my surgeon to conduct the peer to peer, hopefully tomorrow or Wednesday. I was told to plan for surgery as scheduled unless I hear otherwise. So fingers crossed and many prayers please that all goes well and I am on the other side by next Monday afternoon.
 

Missy45

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Yes, I have Aetna too and have dealt with that same independent company they use to do the dirty work. They denied me for everything every step of the way from the MRI to the surgery, even to the darn raised toilet seat! :censored:

Your surgeon’s office will be able to handle it. I never had a peer-to-peer that didn’t do the trick. I had never had physical therapy or an injection for my hip, and never had a diagnosis of arthritis before. What I had was a hip that had to be replaced if I was going to be able to walk again and my surgeon’s office was able to communicate that effectively.

I’m so sorry you are dealing with this. It is hard having that stress and anxiety on top of everything else.

Good luck! :flwrysmile:
 
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DA32561

DA32561

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@Missy45 Thank you for the encouragement. I am in so much pain and to hear about the denial was a hard blow this morning. I am so happy that I was able to hear from others that they went through the same thing and it turned out OK. I hope you are doing well these last two months. I had my left THR done 3 years ago and I can't wait to get this next one done and behind me too.
 
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DA32561

DA32561

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@Jaycey No unfortunately not yet. I was told that they would be trying to do the peer to peer today or tomorrow. I was advised to proceed this week as planned, until I hear otherwise, so I have stopped all NSAIDs and supplements. The messages I have been receiving on this site about others positive outcome are really helping me to keep positive and I want to thank everyone. I will post as soon as I hear any news. Until then...

:fingersx::fingersx::fingersx::prayer::prayer::prayer:
 
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DA32561

DA32561

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GREAT news! I just got the call today that my surgery was approved by my insurance company. I was quite emotional when I heard, it was such a huge relief. Thank you everyone who reached out to give me advice and assurance. I truly appreciate it. Now just need to hang on for a few more days, Monday can't come fast enough.
 
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djklaugh

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@DA32561 :yes!: That is wonderful news! I am so glad to see this was successfully resolved. On ward to Monday!
 

Pumpkin

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Sigh of relief that you were approved and will be having your THR as planned on Monday.
Wishing you smooth sailing from here on through recovery.
 

CG'sknees

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I’m so happy to read that it was approved. I faced the same stress last week, with insurance denial because they said no X-rays were provided to them and surgeon’s office claiming that they were, Bla Bla bla. So stressful in an already stressful time!!!!
Thankfully mine was also approved and I’m on for surgery on 17th. Best of luck to you!!
 

Layla

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Happy Friday! :wave:
Good to read the great news and thankfully not long now until your big date.
Wishing you comfort over the weekend and will look forward to following your healing journey on the recovery side. Wishing you all the best!
@DA32561
 

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